Access to Care in Denver: Progress Report of the Denver Access to Care Task Force

Transcription

1 Access to Care in Denver: Progress Report of the Denver Access to Care Task Force Prepared by Lisa McCann, PhD, in collaboration with Bill Burman, MD, Emily McCormick, MPH, and Lourdes Yun, MD, MPH August 27, 2013

2 Table of Contents Executive Summary... 3 The Work of the Task Force... 4 Figure 1: Denver Access to Care Task Force Phased Activities... 5 The Need for Health Coverage in Denver... 5 Table 1: Health Insurance Coverage in the City and County of Denver, Figure 2: Lack of Insurance by Demographic Group... 6 Figure 3: Denver Residents Eligibility for Medicaid and Subsidies on the Exchange... 7 Best Practices - Massachusetts... 8 Best Practices - Seattle and King County, Washington... 8 Current Enrollment Practices and Barriers to Enrollment in Denver Table 2: Barriers to Enrollment in Denver Preparations for the Medicaid Expansion and the Exchange Challenges and Gaps in Access to Care in 2014 Key Informant Interviews Current Payment Sources and Populations Served Table 3: Payment Sources and Special Populations Enrollment Services Waiting Lists and Turning Patients and Clients Away Planning for Expanded Populations in Primary Care Planning Mental Health Care Planning Substance Abuse Treatment Planning Dental Care Planning Challenges and Gaps Foreseen in Access to Care in Table 4: Challenges and Gaps Foreseen in Access to Care in Enhanced Opportunities for Cooperation with the ACA Modeling Enrollment and Access to Care in Denver Phase 1 Goals, Strategies and Activities Table 5: Denver Access to Care Task Force Phase 1 Goals Support the expansion of health insurance under the ACA Facilitate work city-wide to enroll at least 40,000 newly eligible persons in Medicaid and subsidized health insurance through Connect for Health Colorado by July 1, Table 6: Evaluating Phase 1 Goals Appendix 1: Denver Access to Care Task Force Members Appendix 2: Organizations Interviewed on Challenges and Gaps in Access to Care Appendix 3: Challenges and Gaps Foreseen in Primary, Specialty, and Behavioral Health Care in Denver

3 Primary Care Specialty Care Mental Health Care Substance Abuse Treatment

4 Executive Summary Approximately one in five Denver residents, more than 100,000 persons, lacks health insurance, and an even higher number lack dental insurance, making it difficult to obtain medical, behavioral, and dental care. Moreover, these types of care are often split between different systems, with little coordination regarding the care of individual patients. The result is expensive, poorly coordinated care with sub-optimal health outcomes. Denver residents and a city-wide, multi-stakeholder steering committee selected Access to Care as one of two priority areas for improving the health of Denver residents in the city s forthcoming Community Health Improvement Plan (CHIP), along with healthy eating and active living to reduce the city s obesity rate. The Denver Access to Care Task Force was set up in February 2013 to identify goals and strategies for improving access to care in the city. It includes representatives from medical care providers, behavioral care providers, governmental organizations, and community-based organizations serving lower-income persons in Denver. The expansion of health care coverage through the Patient Prevention and Affordable Care Act (ACA) provides an unprecedented opportunity to increase access to care in Denver. The ACA will markedly expand eligibility for Medicaid and provide governmental assistance for many people to purchase health insurance in As such, the initial priority of the Task Force has been to assist in the forthcoming stages of the ACA roll-out in Denver. The Task Force also envisions a longer-term role in supporting greater care coordination for individual patients, and greater collaboration between public health and human services officials, health care providers, behavioral health care providers, and community-based organizations serving lower-income persons in Denver. The Task Force anticipates four phases of activity to support greater access to care for Denver residents. Phase 1 supports the coming phases of implementation of the ACA in 2013 and into Phase 2 will build capacity for the care of persons becoming eligible for Medicaid and the new insurance plans in Phase 3 will support increased care coordination for individual patients among safety net providers in Denver. Phase 4 will promote better system collaboration among safety-net providers and other organizations serving lower-income persons in Denver, an effort that is likely to last at least five years. The initial work of the Task Force for Phases 1 and 2 has involved an extensive environmental scan of access to care issues in the City and County of Denver. These are outlined in this report, and include the following: The current need for insurance coverage among city residents; Best practices in other states and cities; Current enrollment practices in Denver for Medicaid and other public health coverage programs; Preparations being undertaken by primary care providers, behavioral health care providers, governmental organizations, and community-based organizations in Denver for the forthcoming changes under the ACA; and Challenges and gaps foreseen in primary care, specialty care, and behavioral health care in Denver, once more people have health care coverage in The Task Force has identified goals for Phase 1 of its work - to support the expansion of health care coverage under the ACA and facilitate the enrollment of at least 40,000 persons in Denver in Medicaid and the new insurance exchange by July 1, It has outlined a set of strategies and activities for meeting these goals, and a strategy for measuring progress in meeting them. 3

5 The Work of the Task Force Approximately one in five Denver residents, more than 100,000 persons, lacks health insurance, and an even higher number lack dental insurance, making it difficult to obtain medical, behavioral, and dental care. Moreover, these types of care are often split between different systems, with little coordination regarding the care of individual patients. The result is expensive, poorly coordinated care with sub-optimal health outcomes. In 2012, a Steering Committee led by Denver Public Health and Denver Environmental Health conducted a series of community meetings to help prioritize topics for the Denver Community Health Improvement Plan (CHIP). Access to Care was selected, along with Health Eating/Active Living and Reducing Obesity, as the two top priorities for improving the health of Denver residents. The Denver Access to Care Task Force was set up in February 2013 to identify specific issues and strategies to improve access to care. The Task Force includes representatives from medical care providers, behavioral health care providers, governmental organizations, and community-based organizations (see Appendix 1 for a list of Task Force members). It has held five regular meetings to date, as well as a special session to learn about safety-net health care coordination in Seattle and King County. The expansion of health insurance through the Patient Prevention and Affordable Care Act (ACA) provides an unprecedented opportunity to increase access to care in Denver. The ACA will markedly expand eligibility for Medicaid and provide governmental assistance for many people to purchase health insurance in Therefore, the initial priority of the Task Force has been to assist in the roll-out of the ACA in Denver. The Task Force also envisions a longer-term role in supporting greater care coordination for individual patients, and greater collaboration between public health and human services officials, health care providers, behavioral health care providers, and community-based organizations serving lower-income persons in Denver. The Task Force anticipates four phases of activity to support greater access to care for Denver residents (see Figure 1). Phase 1 supports the coming phases of implementation of the ACA in 2013 and into Phase 2 will build capacity for the care of persons becoming eligible for Medicaid and the new insurance plans in Phase 3 will support increased care coordination for individual patients among safety net providers in Denver. Phase 4 will promote better system collaboration among safetynet providers and other organizations serving lower-income persons in Denver, an effort that is likely to last at least five years. The initial work of the Task Force has involved an extensive environmental scan of access to care issues in the City and County of Denver, including: the current need for insurance coverage among city residents; best practices in other cities; current enrollment practices in Denver for Medicaid and other public health coverage programs; preparations being undertaken by primary care providers, behavioral health care providers, governmental organizations, and community-based organizations in Denver to prepare for the forthcoming changes under the ACA; Preparation for Phase 2 has included an in-depth study, through key informant interviews with the principal safety net providers in Denver, to identify their current level of planning for handling the expanded populations who are likely to seek their services in 2014, and the challenges and gaps they 4

6 foresee in primary care, specialty care, and behavioral health care. The results of these assessments are reported in the following sections of this report. Figure 1: Denver Access to Care Task Force Phased Activities The Need for Health Coverage in Denver The American Community Survey (ACS) estimated that about 104,000 persons, or nearly 17% of Denver residents, were without health insurance in 2011, while the Colorado Health Access Survey (CHAS) estimated that 20% of Denver s residents were uninsured in the same period (Table 1). 1 Thus, approximately one in five Denver residents lacks health insurance, compared to a somewhat lower rate of un-insurance (16%) both in Colorado and the US as a whole. 2 1 American Community Survey (ACS), 2011 and Colorado Health Access Survey (CHAS), Detailed ACS data on uninsured for the City and County of Denver were prepared by the Colorado Health Institute (CHI). 2 Colorado Health Institute (2012), Counting Colorado s Uninsured and US Census Bureau (2011), Current Population Survey (CPS). 5

7 Percentage Uninsured Table 1: Health Insurance Coverage in the City and County of Denver, 2011 Health U.S. Citizens, Nationals, and Legal Undocumented Total Population Insurance Immigrants Persons Status Number Percent Number Percent Number Percent Uninsured 104, % 84, % 19, % Insured 517, % 498, % 18,877* 49.0% Totals 621, % 583, % 38, % *This number may be over-estimated due to difficulties sampling this population. Source: 2011 American Community Survey, Data prepared by the Colorado Health Institute The number of uninsured U.S. citizens, nationals and legal immigrants, who will be potentially eligible for Medicaid or insurance plans on the Exchange, is estimated at 84,450 persons, or 14.5% of the population. The vast majority of these (75,483 persons, 89%) are likely to meet the eligibility requirements in 2014 either for expanded Medicaid (41,246, 49%) or subsidized insurance plans on the Exchange (34,237, 41%). Undocumented persons and some legal residents will not be eligible for the new forms of coverage. While there is no formal assessment of documentation status within Denver, the ACS estimates that there are 38,605 undocumented persons in the city, nearly half of whom reported that they did not have health insurance. Many are being cared for by Denver s safety net clinics. Figure 2: Lack of Insurance by Demographic Group Although all parts of the community are affected by high rates 50% of un-insurance, certain subpopulations were even more likely to 26% 40% 29% 30% 23% 21% be uninsured, including young adults 17% 20% 14% 9% 11% 14% 13% years of age (26%) and adults years of age (23%) (Figure 2). 10% 1% More men were uninsured (17%) than 0% women (14%), and Hispanics had the highest rate of un-insurance of any racial or ethnic group (29%), followed by Blacks (14%) and other races (13%). Whites had the lowest rate of un-insurance (11%). Source: 2011 American Community Survey and U.S. Census Medicaid eligibility will cover legal residents earning up to 133% of the Federal Poverty Level (FPL), or $15,282 per year for a single person and $31,322 for a family of four, regardless of their marital status or whether they are parents (Figure 3). Insurance subsidies will be available for legal residents earning % of FPL, or up to $45,900 per year for a single person and $94,200 for a family of four. More than 41,000 persons in Denver, or 40% of the currently uninsured population, will be eligible for Medicaid in More than 34,000, or 33% of the currently uninsured, will be eligible for subsidies when purchasing insurance on the Exchange. About 7000 persons, or 7% of the uninsured population, will not qualify for subsidies, but can purchase insurance on the Exchange at rates that are 6

8 projected to be less than in the individual insurance market today. 3 The map below shows the distribution of persons at or below the FPL in Denver. The darker shaded areas indicate neighborhoods where a higher percentage of residents will qualify for health coverage under the ACA in Figure 3: Denver Residents Eligibility for Medicaid and Subsidies on the Exchange Total Eligible for Medicaid and Exchange: 82,564 80% of uninsured 3 US Department of Health and Human Services (2013), Market Competition Works. 7

9 Best Practices - Massachusetts Massachusetts instituted a healthcare reform in 2006 that included an individual insurance mandate, expansion of Medicaid, a new insurance exchange, and a prohibition on denials for preexisting conditions. Because the Massachusetts reform was a prototype for the ACA, experiences there could indicate what is ahead for Colorado and the US as a whole in regard to insurance coverage and access to care. Massachusetts differs from Colorado in its low rate of un-insurance even before the 2006 reform. It had only 7.4% uninsured in 2004, the lowest rate in the US, which averaged 14.3% at that time. 4 Colorado s rate of uninsured in 2004 was 17%. 5 Despite its low rates to start with, Massachusetts was able to drop its uninsured rate by more than half, to 3.1% in 2011, while the national rate rose to 15.7% in the same period. Massachusetts continues to have the lowest rate of un-insurance in the US, but by a much greater margin than before the reform. Its remaining uninsured are predominantly young adults, males, Hispanics, and undocumented persons, much like the demographic profile of Colorado s current uninsured population. 6 Massachusetts has seen good compliance with the individual insurance mandate among its citizens. Only 1% of residents were assessed a tax penalty in 2010 for lack of insurance, with the penalty being fixed at 50% of the lowest-priced plan on the state exchange. The reform has not crowded out employer-sponsored insurance (ESI), which was high in Massachusetts before the reform 70% in 2005 and rising to 76% in In contrast, the US rate of ESI fell from 69.7% in 1999/2000 to 59.5% in Colorado s ESI rate fell from 71.8% in 1999/2000 to 63.0% in 2010/ Massachusetts has had 8% fewer ER visits since implementing its healthcare reform, an important indicator of better access to primary and preventive care. 8 It has also seen gains in the Health Status Index (HSI) relative to other states. 9 The HSI measures BMI, physical activity, and mental health status. It had higher health care costs than the US as a whole, both before and after its reform, but was able to contain costs on individual premiums, for which there was no net increase between 2006 and Best Practices - Seattle and King County, Washington The Task Force held a special session on May 30, 2013 with Janna Wilson, Senior External Relations Officer for the Seattle and King County Public Health Department, to learn about Seattle s experience in coordinating and integrating services among safety-net medical and behavioral health providers, community-based organizations, and the public health and human services departments. The Task Force also learned about Seattle s efforts to better integrate medical and behavioral health care, 4 Blue Cross and Blue Shield Foundation of Massachusetts and Massachusetts Medicaid Policy Institute (2013), Health Care Reform in Massachusetts, Expanding Access to Health Insurance Coverage: Assessing the Results. 5 Colorado Health Institute (2006), Profile of the Uninsured in Colorado: An Update for Blue Cross and Blue Shield Foundation of Massachusetts (2013), ibid. 7 State Health Access Data Assistance Center (2013), State-Level Trends in Employer-Sponsored Health Insurance. 8 Washington Post (2012), Six Ways Romneycare Changed Massachusetts. 9 Ibid. 10 Ibid. 8

10 and to support expanded health care coverage under Medicaid and the new insurance Exchange in Seattle and King County have a similar rate of uninsured as Denver, 16%, with a significant variance in health care coverage in different parts of the city, from as low as 3% to as high as 30%. Like Colorado, Washington State has elected to expand Medicaid, and is preparing to open its own Exchange in October 2013 to offer subsidized health insurance plans to those who qualify. Seattle has been involved in multi-stakeholder system integration efforts since early in 2011, looking forward to the full implementation of the ACA in As such, it has had a head start in these important processes, from which Denver and its Access to Care Task Force can learn and profit. This process in Seattle has culminated in the recent production in July 2013 of a Transformation Plan for King County to create an accountable, integrated system of health, human services, and community-based prevention. 11 The recent plan was informed by a 30-member panel with representatives from human services, health care delivery, prevention, public health, philanthropy, labor, local government, and other sectors a similar composition to the Denver Access to Care Task Force. The Plan aims to reduce significant inequities in health and well-being across the County through a collective community response focusing on prevention, recovery, and provision of services. It includes strategies at the individual level for adults with complex health and social needs, and at the community level for high-risk communities with the greatest disparities. Seattle and King County have also made iterative steps since 2006 to better integrate medical care and behavioral health care in primary care settings, through a state-wide mental health integration program, a County behavioral health sales tax, federal integration grants from SAMSHA 12 and HERSA, 13 a demonstration project for persons eligible for both Medicaid and Medicare, and a CMMI 14 planning grant. Washington State Medicaid is handled as managed care, which requires care coordination and management of complex social conditions for beneficiaries. Care coordinators are embedded in primary care clinics and are trained by and work with consulting psychiatrists from the University of Washington. Primary care providers are given high-quality training to handle mental health issues within the primary care setting, but care coordinators are also able to transfer patients to specialized community mental health agencies if their mental health issues need more attention. Seattle and King County have also been active in planning efforts for expanding health care coverage under Medicaid and the new insurance Exchange in The Public Health Department set up a 20-member steering committee to direct efforts towards enrollment in Medicaid and the purchase of health insurance by residents, in three phases. Phase 1, from January through May 2013 involved analyzing and mapping the uninsured in the County and planning for an outreach campaign to support enrollment. Phase 2, from June through October 2013, involves training, technical assistance, and distribution of materials to an extensive network of community-based partners and launching a website to track enrollment events and progress. Unlike the Denver Public Health Department, the Seattle and King County Public Health Department in the in-person lead for enrollment assistance in the county, and as such, plays a direct role in outreach efforts. 11 King County, Washington (2013), Health and Human Services Transformation Plan, June 26, Substance Abuse and Mental Services Administration. 13 Health Resources and Services Administration. 14 Center for Medicare and Medicaid Innovation. 9

11 Phase 3 will begin with the opening of the Washington State Exchange in October 2013 and extends through April 2014, to execute the plans for supporting enrollment. City departments are all being engaged to assist in the enrollment effort, through activities such as ads in Parks Department fliers, providing speakers to inform city employees and citizen groups about the forthcoming changes under the ACA, and efforts to enroll people who are in jails. After the forthcoming changes under ACA in 2014, the Seattle and King County Health Department and its ACA Steering Committee hope to reduce the uninsured in the county from 16% to 4%, and to narrow the range of uninsured to between 1 and 10%. Current Enrollment Practices and Barriers to Enrollment in Denver 126 Denver-based organizations were surveyed in April 2013 to gather information about their current enrollment practices for Medicaid, CHP+ and other medical assistance programs, and current preparations for the forthcoming expansion of Medicaid and introduction of the state Exchange. 88% of responding organizations either directly enrolled clients in Medicaid or provided services linking clients to enrollment. Many others enrolled or assisted in the enrollment of clients in CHP+, CICP, and other health coverage and assistance programs. Just over half of the organizations surveyed (52%) provided education to patients or clients on Medicaid eligibility and enrollment. Respondents noted a number of current barriers to enrollment in Medicaid, CHP+ and other medical assistance programs, many of which are likely to be exacerbated in the forthcoming expansion of Medicaid in 2014 (Table 2). Important barriers related to the clients themselves included transience, culture and language barriers, clients lack of understanding regarding their eligibility, the documentation required to process cases, and correspondence they receive from state and other authorities. Structural barriers to enrollment included a lack of resources within organizations for processing cases, challenges with the use of the Colorado Benefits Management System (CBMS) and the Colorado Program and Eligibility Application Kit (PEAK), and long waiting times and other problems in the processing of applications. Several barriers to accessing primary care were noted for clients who do obtain benefits, such as lotteries and waiting lists for care providers, confusion regarding benefits, and clients missing redetermination dates. Moreover, many people do not qualify for Medicaid and cannot afford insurance, including large numbers of undocumented families in Denver, while CICP coverage for persons living outside the City and County of Denver remains problematic, with persons outside Denver seeking care under CICP, while Denver-based providers are not authorized to extend it. 10

12 Table 2: Barriers to Enrollment in Denver Barriers Related to Clients Transience Culture and language barriers Not understanding eligibility criteria Documentation requirements Misunderstanding correspondence received from authorities Not qualifying for Medicaid Inability to afford insurance Barriers Related to Organizations Lack of resources for processing cases Challenges with the Colorado Benefits Management System (CBMS) Challenges with the Colorado Program and Eligibility Application Kit (PEAK) Long processing times and other problems in the processing of applications Barriers for People with Benefits Lotteries and waiting lists for access to health and behavioral care providers Confusion regarding benefits Missing re-determination dates Non-Denver patients attempting to use Denver safety net clinics Preparations for the Medicaid Expansion and the Exchange Many of the organizations surveyed were already engaged in activities to prepare for the forthcoming phases of the ACA rollout in About one third (32%) have already expanded their Medicaid enrollment services, while the same proportion are planning to expand services. Nearly half of the organizations surveyed (49%) had either submitted applications to become certified, in-person assistance sites for Connect for Health Colorado, or were planning to do so at the time of the survey in April 2013, to help clients navigate the Exchange and purchase subsidized insurance. 23 organizations in Denver were awarded grants to become certified assistance sites beginning in October Just over half of the organizations surveyed (53%) were already engaged in educating their staff about the forthcoming ACA changes, while 47% were planning to do so. 42% of organizations were already engaged in educating healthcare providers, while 47% were planning to do so. 51% were already engaged in educating patients and clients, while 43% were planning to do so. 50% of organizations were already conducting outreach activities, while 52% were planning to do so. Some of the activities underway or planned included developing training and education materials, conducting outreach and education events, advocating with state authorities for policy changes, projecting populations that will be eligible for Medicaid in 2014, coordinating with the county human services office and multi-stakeholder collaborative groups, applying for grants, and taking steps to connect medical and behavioral health providers and systems. Respondents had different levels of comfort in answering questions about the forthcoming changes under the ACA. About a quarter of the respondents (23%) felt very comfortable about their knowledge of the ACA, while nearly half (46%) felt only somewhat comfortable. About one-third (31%) felt either somewhat uncomfortable (23%) or very uncomfortable (8%) about their knowledge of the ACA. Given that the majority of respondents did not express a high level of comfort with their knowledge of the ACA, most organizations could benefit from staff training about the ACA rollout, and particularly about its complex details regarding state decisions, the Medicaid expansion, the insurance plans to be offered on Connect for Health Colorado, how the premium tax credits will work, and how the expansion of Medicaid will interface with other programs. 11

13 Respondents indicated a number of important tools and types of training that would assist them in preparing for the forthcoming ACA changes. Some of the tools included seminars and meetings, websites and printed materials to give to staff, patients, and clients, training in outreach and communication skills, specific trainings about Medicaid and the insurance exchange, trainings for specific professional groups and about how particular beneficiary groups will be affected by the ACA changes, and financial resources to support the new efforts. The survey pointed out many projected challenges and gaps likely to be seen with the rollout of the ACA. Projected challenges related to the new programs included the short time-frame for implementation, vague or confusing program guidelines, IT challenges with the exchange, and potential difficulties in communications with HCPF and the exchange authorities. Likely gaps related to the capacity of enrollment and assistance organizations included shortfalls in knowledge, training, communication skills, networking, and funding. Gaps related to clients included a lack of knowledge about the forthcoming changes, what they will be eligible for, and health insurance vocabulary. There were concerns that low-income families who do not qualify for Medicaid may not be able to afford insurance on the exchange, even with the tax credits offsetting the cost, that people may churn between Medicaid and the exchange as their income changes, and that certain communities may excluded or actually lose services in the transition, such as undocumented and HIV positive persons. Finally, there were concerns that many people with benefits will not be able to access care due to the lack of staff and facilities, both for primary care and behavioral care. Challenges and Gaps in Access to Care in 2014 Key Informant Interviews The above survey on enrollment and ACA preparations was followed by extensive key informant interviews with 27 directors and clinic managers of 16 safety net providers in Denver that offer primary care, specialty care, mental health care, substance abuse treatment, and dental care to lower-income persons. Also included was the designated Behavioral Health Organization coordinating Medicaid specialty mental health care in Denver. The interviews sought to further investigate the projected challenges and gaps in access to care across the various areas of medical and behavioral health care as more people obtain Medicaid coverage and new insurance plans through the Exchange The evaluation was conducted to support the Denver Access to Care Task Force in closing these gaps and better coordinating care among safety net providers in the city. Eleven of the 17 organizations interviewed (65%) offered primary care services and 4 (24%) offered some specialty care on their premises, while 3 (18%) had systems for referral to specialty care within a larger hospital system. 15 of the 17 organizations (88%) offered mental health care and 9 (53%) offered substance abuse treatment. 6 organizations (35%) offered dental care. See Appendix 2 for a list of the organizations interviewed and the principal safety net services each offers. Current Payment Sources and Populations Served All 17 organizations provided services to Medicaid patients, while 13 (76%) provided services to patients with CHP+ (Table 3). For some organizations, patients on these public assistance programs made up only a small proportion of their total caseloads, while for others, a majority of their patients 12

14 had this type of coverage. The average proportion of Medicaid and CHP+ patients seen by these organizations was 39%, and ranged from almost none to 88%. 11 organizations (65%) provided services to patients with Medicare, but these patients made up only a small proportion of their caseloads on average (2%). Nearly all the organizations (16, or 94%) provided services to uninsured patients, usually on a sliding fee scale where the patient makes a contribution to the cost of care at the time of the visit. 7 organizations (41%) provided services to uninsured persons through the Colorado Indigent Care Program (CICP). The average proportion of uninsured and CICP patients seen by these organizations was 52%. Table 3: Payment Sources and Special Populations Average Estimated Proportion of Caseload Organizations Providing Care to Patients With: No % Medicaid % CHP Medicare % No Insurance % CICP 7 41 Private Insurance % Organizations Providing Care to: No % Homeless Persons not available Undocumented Persons not available Ten organizations (59%) provided services to patients with private insurance, and these patients made up 11% of their caseloads, on average. Thirteen organizations (76%) provided services to homeless persons, and 16 (94%) to undocumented persons, but organizations did not generally track the proportions of patients in these categories. Enrollment Services Thirteen of the 17 organizations interviewed (76%) had on-site enrollment assistance services to help patients get enrolled in Medicaid and CHP+, and so will be well-placed to assist persons who become eligible for Medicaid in 2014 to get enrolled. 7 organizations (41%) received grants to become Health Coverage Guides for Connect for Health Colorado, to help clients check for eligibility and enroll in subsidized insurance plans to be offered on the Exchange starting in October Waiting Lists and Turning Patients and Clients Away Nearly 60% of the organizations interviewed (10 of 17, 59%) had waiting lists for patients to access services for the first time, with an average wait time of 4 weeks. Some organizations made exceptions for pregnant women, children, people recently discharged from a hospital, and people with certain Nearly 60% of safety-net organizations interviewed had waiting lists Average Wait Time: 4 weeks types of payment sources, such as those covered under a state contract for indigent mental health care and those with private insurance, citing the need to balance paying and non-paying clients. Other organizations used waiting lists strictly on a first-come, first-served basis. Several organizations did not 13

15 bother to have a wait list, because there would be too many people on it, with no means of assuring that patients or clients could be seen within a reasonable time-frame. Eleven organizations (65%) were forced to turn people away regularly or deny service, most 65% had to turn patients away often due to a lack of staff and resources and the need to prioritize the groups to whom they extend services. Criteria for turning people away included the patient or client not being a good match with the mission of the organization, being less in need of care than others, and having an option to go elsewhere for care. Most organizations that turned people away did their best to refer them to other organizations that might be able to help. Planning for Expanded Populations in 2014 Fifteen of the 17 organizations interviewed (88%) indicated that they were planning to take additional Medicaid patients in Those not planning to take on more Medicaid patients cited capacity problems as the reason, and in particular the inability to hire new staff in advance of the Medicaid 14 82% plan to take new Medicaid patients in % plan to take patients with insurance from the Exchange expansion. Twelve organizations (71%) indicated that they were planning to accept patients with insurance purchased on the Exchange in 2014, some under their own organizations insurance plans to be offered on the Exchange. Some organizations were unsure if they would be taking new patients with insurance from the Exchange, or were planning not to do so. The reasons for this uncertainty, or deciding against taking insured patients, included not having the staff and resources to take on more patients even if they had insurance, not expecting their current clientele to be able to purchase the new insurance plans, not expecting the newly insured to approach their clinics, and not having any history of working with insured patients, such that their mission statements and current business models would have to be revised if they took on these patients. More than a third of the organizations interviewed (7,or 41%) had done some modeling of the projected populations their organizations are likely to see in 2014 that will be newly eligible for Medicaid or insurance on the Exchange. Modeling for increases in Medicaid caseloads were more common than for projected patients with insurance from the Exchange, with some organizations estimating particular numbers of new patients that ranged from hundreds to tens of thousands, and others reporting percentages of current, uninsured patients getting covered, from 15 to 80 percent. About a third of organizations (6, or 35%) had only a vague idea of how their populations might change, without any specific data for the trends they foresaw (for example predicting that the majority of their caseload or thousands of their patients would be eligible for Medicaid). Organizations specialized in providing services to children did not expect a large increase either in Medicaid enrollment or insurance coverage in 2014, given that children are already widely covered under Medicaid and CHP+. Similarly, organizations seeing large numbers of undocumented persons did not expect to see big changes in coverage for their caseloads, since undocumented persons will not be eligible for the new forms of coverage. The organizations were asked about changes they were thinking about or already making to get ready for the expanded populations they are likely to see in 2014, and the changed payment sources

16 these patients and clients are likely to have. In the sections that follow, planned activities and changes are outlined for primary care, mental health care, substance abuse treatment, and dental care services provided by safety net clinics in Denver. Primary Care Planning Organizations were planning for a variety of new activities in or around primary care to support the forthcoming health coverage changes. Some were planning to make a big push for Medicaid enrollment, for example to get current CICP patients and people on the CICP waiting list on Medicaid as soon as possible, or to get newly eligible people enrolled in Medicaid who have been paid for through charity funds before As mentioned above, 13 of the 17 organizations interviewed (76%) already have on-site enrollment assistance services for Medicaid and CHP+; 7 organizations (41%) received grants to become Health Coverage Guides for Connect for Health Colorado, and will be supported by grants to increase their staff and resources for helping clients enroll in insurance plans on the Exchange. Many organizations were making changes to their operations and facilities, such as extending working hours, expanding current facilities, moving to new facilities, and building new facilities from scratch. They were looking at adding a variety of staff senior management staff to help run the more complex operations; administrative staff to facilitate enrollment, set up contracts with insurance companies, and bill for both Medicaid and private insurance; navigators to assist in care coordination for patients and clients; and providers to give care. The focus for new providers is primarily in internal medicine and family medicine rather than pediatrics and obstetrics and gynecology, given that it will be largely an adult, non-pregnant population that acquires the new forms of coverage in Some organizations were already adding staff, while others recognized the need to do so, but were proceeding cautiously on a wait and see basis, given that reimbursement for the expanded services will not be forthcoming until well into 2014, and that not all the newly eligible persons will get coverage and show up for care at the start of the year. Some organizations are making their expansion plans for later in 2014 or into 2015, once the demand for services and the revenue streams from the new forms of coverage become clearer. Some organizations, including those that see primarily children, who are already well-covered by public insurance programs, were not planning for expanded caseloads or for significant changes in their operations. They were nevertheless anticipating better financial outcomes, more sustainability in their programs and operations, and less of a need for subsidization from parent organizations with more universal coverage of their current patient populations. In addition to the financial benefits, some clinics expected advantages such as the ability to reduce waiting lists and wait times for patients to access care. On the other end of the spectrum of eligibility, clinics that see a large number of undocumented persons, who will not be eligible for the new types of coverage, were also not making many plans for changes. For some clinics, the structure of the clinic precluded the addition of patients, even if they came with Medicaid or insurance coverage. An example are clinics that are set up in large part to serve graduate medical education and whose providers are primarily residents; these hospitals do not plan to increase the number of residents passing through their training programs, even if a higher percentage of patients had better payment sources. Some clinics were planning to make major changes to their business models, to accommodate Medicaid patients or insurance holders for the first time and possibly market themselves for the first 15

17 time as being open to new patients. At the same time, they wish to retain their central or founding missions to serve persons without coverage or another place to get care. These organizations are wondering how adding these new types of patients and payment sources will impact their clinics. For example, clinics taking insurance for the first time are trying to anticipate what the different needs and demands of an insured population will be, and how to prepare for this. They wish to be able to see insured patients in order to ensure that their current patients can continue getting care at the clinic once they get insurance. Other clinics were not making such a push to accommodate privately insured patients, because they do not expect their current populations to be willing or able to buy insurance, or because they do not expect people with private insurance to come to their clinic, even if they were patients at the clinic before getting the insurance. One organization that already has a large insured population, but is adding a larger Medicaid component to respond to the Medicaid expansion, is trying to equalize the experience of these different patients, also to facilitate smooth transitions and continuity of care as people move between Medicaid and private insurance plans, as they are likely to do in 2014 as their employment and income status changes. Most organizations were expecting better financial results in 2014 and beyond, with more revenues coming from the patients themselves and therefore greater self-sufficiency in programs with the expansion of Medicaid and the wider availability of insurance among their patients and clients. However, because Medicaid reimbursement does not cover the cost of services and many patients and clients will continue to be ineligible for Medicaid and unable to purchase insurance, many organizations were concerned that they could lose grant funding and other sources of revenue that have supported their operations up until now and that they will still need to be viable. Mental Health Care Planning Two of the organizations interviewed who offer mental health care services had recently moved to newer, larger premises, and several are planning for expansions or moves in the near future, as well as partnerships with other organizations, to accommodate more clients in Both of the adult inpatient psychiatric units in the City and County of Denver, at Denver Health and Porter Hospital, are prepared to expand the number of beds in their current facilities if needed in Several of the mental health care organizations interviewed had already added staff or have plans to do so in the near future to handle increased caseloads in Many recognized the need for a variety of staff - providers, patient navigators and care coordinators, billing staff, and administrative staff to assist with the transition to electronic medical records and scheduling appointments - but most are unable to add these staff until the new payment sources are actually in place for clients in Some organizations are reviewing their staff s training and credentials and swapping staff between programs to make sure they meet the criteria for obtaining reimbursement for mental health care under Medicaid and the new insurance plans in Many organizations are planning to add billing staff, both for Medicaid and for clients coming in 2014 with private insurance through the Exchange. Some organizations recognized that it will not be easy to get on the insurance panels of many different insurance companies by 2014, and as a result are prioritizing Medicaid billing in the short run. One organization will coordinate with a county mental health agency to assist in billing for private insurance. Another with staffing needs in several areas is planning to use interns and funding from 16

18 foundation grants to bridge their staffing gap until reimbursement is forthcoming from Medicaid and private insurance payments in One large provider of mental health services noted that it was limited in taking on new patients even if they came with a payment source, due to severely limited capacity now, but that new payment sources should at least better cover the current caseload and make their programs more sustainable. Many of the mental health care providers were already providing care in integrated programs with primary care clinics, and were planning to continue this focus to deal with the projected flux of new clients in 2014, many of whom are expected to have mild to moderate mental health conditions that are amenable to treatment in an integrated primary care setting. Some had already added primary care physicians who are able to prescribe medications, and some will focus on adding advanced practice providers nurse-practitioners and physician assistants, to help with the medical side of mental health care. Most mental health care providers were not planning to take on high-need patients, who are seen now primarily by the Mental Health Center of Denver (MHCD) and will continue to be seen by MHCD in Even MHCD with its specialization in high-need cases is gearing up for an increase in mild to moderate cases in need of short-term care in Many mental health care organizations mentioned areas into which they would like to expand in order to create better access, including a number of non-traditional, non-face-to-face methods of seeing clients, such as telephone counseling, online chat rooms, and tele-psychiatry to make better use of the extremely limited number of psychiatrists in the state. All mentioned that they expected to face challenges in getting reimbursement for these services that are not delivered in traditional face-to-face meetings between providers and clients. Substance Abuse Treatment Planning Organizations are also gearing up for providing more substance abuse treatment in 2014, and are looking forward to better reimbursement for this type of treatment, both from Medicaid and insurance plans sold in the Exchange. A new Medicaid substance abuse benefit is expected to be rolled out in 2014, and substance abuse treatment is among the 10 essential health benefits that must be provided by plans sold in the Exchange. As such, organizations are looking for information about how to bill for these services in Two organizations were planning to add substance abuse treatment for the first time. Many are reviewing the training, certifications, and supervisory requirements for their staff, to allow them to obtain reimbursement both from Medicaid and the new insurance plans for substance abuse treatment. Some organizations are adding new substance treatment staff, while many are assisting their current staff to obtain needed credentials such as Certified Addiction Counselor (CAC). One organization mentioned wanting to better integrate mental health and substance abuse treatment, which has been challenging up to now because of the different payment sources and billing codes for the two, despite their frequent co-occurrence in the same patient or client. Another organization that is primarily a substance abuse treatment provider has recently placed its staff, through partnerships with other organizations, in a number of primary care clinics to better reach clients who need these services. 17

19 Organizations are using a number of new tools to assist them in substance abuse treatment, such as bracelets for monitoring alcohol levels and smart phone apps that help clients manage their substance use. Dental Care Planning Six of the 17 organizations interviewed (35%) offered dental care, but not all offered a full range of dental services. Only two organizations were planning to add more dental services in One organization mentioned that it was not planning to add dental services due to the high cost of setting up and staffing a dental clinic. Children have been prioritized for dental services up to now, given the limited capacity of clinics, the high level of demand, and the fact that Medicaid has not yet covered adult dental services. Organizations have not yet had time to respond to and plan for implications of the recent Colorado legislative decision to add an adult Medicaid dental benefit in mid-2014, nor was dental care included among the 10 essential health benefits to be covered under the new insurance plans to be sold in the Exchange. Challenges and Gaps Foreseen in Access to Care in 2014 Organizations were asked about the challenges they foresee in 2014, once a larger number of people are covered under Medicaid and private insurance. Appendix 3 provides in detail the particular challenges and gaps foreseen for primary care, specialty care, and behavioral health care. Table 4 summarizes the challenges and gaps related to the new programs themselves, the organizational capacity of safety net providers, and factors related to patients and clients. Important challenges related to the new programs included a lack of information and misunderstandings about the ACA, both within organizations and among the general public. A recent Kaiser Family Foundation poll found that 42% of Americans were unaware that the ACA was an approved law. 15 There is much confusion about program guidelines and what the plans sold on the exchange will cover. There is a big concern that people will churn between Medicaid, the Exchange, and being uninsured as their income and employment status change. Providers are concerned about low reimbursement rates and continued difficulties getting reimbursement from Medicaid, and about challenges in getting on insurance panels and in provider networks for the new insurance plans. Important challenges related to organizational capacity included a lack of funding for enrollment assistance guides to help get people enrolled, especially for Medicaid. Of great concern is the lack of capacity to handle the inflow of new patients in 2014, given the waiting lists already in place and the fact that many organizations already have to turn people away. Concerns were particularly high about the lack of capacity to see new mental health clients, especially severe cases. Nearly all organizations lack funding to hire new providers in all fields before the new coverage regimes are put into place and are proven to work. Moreover, even if funding were available now, there is a lack of providers in many fields relevant to the expansion of coverage, including internal medicine, family medicine, nurse- 15 Kaiser Family Foundation (2013), Kaiser Health Tracking Poll: April

20 midwifery, and all types of behavioral healthcare providers. Particularly concerning is the lack of an organized referral system from primary to specialty care. Important challenges related to patients and clients included the potential inability of many people to afford insurance even with the subsidies that will be offered, the possible lack of enthusiasm for enrolling in Medicaid or purchasing insurance on the Exchange, especially in the early years of the expansion, and the need for education among the newly covered about how to use the coverage appropriately and avoid unnecessary use of emergency rooms and urgent care clinics. Table 4: Challenges and Gaps Foreseen in Access to Care in 2014 Gaps: New Programs Gaps: Organizational Capacity Gaps: Patients/Clients Lack of information and misunderstandings about the ACA, within organizations and among the general public and patients/ clients Vague or confusing program guidelines, lack of information about plans and coverage, and how people might lose coverage Short time-frame for implementation Potential IT challenges with CBMS and the Exchange Difficulties in communications with HCPF and Exchange authorities Churn of people between Medicaid, insurance plans, and un-insurance Exclusion of certain communities Difficulties getting on insurance panels and into provider networks Low reimbursement rates for Medicaid Difficulties securing reimbursement for mental health care and substance abuse treatment Lack of reimbursement for care coordinators and wrap-around social services Lack of funding and capacity for enrollment assistance Lack of capacity to handle the inflow of new patients in longer waiting lists, turning more people away Large lack of capacity to see new mental health clients, especially severe cases Shortage of beds in in-patient psychiatric units and poor follow-up after discharge Lack of funding before 2014 to hire providers in all fields Lack of providers available to hire even when funding will be available: Primary care - internal medicine, family medicine, nurse-midwifery Behavioral care - psychiatrists, psychiatric nurses, psychologists, LCSWs, MSWs, culturally diverse workers at all levels Substance abuse Board Certified Addictions Physicians, Certified Addictions Counselors Lack of funding for care coordinators Lack of an organized referral system from primary to specialty care Challenges to organizational missions when patients and clients have coverage in 2014 and beyond Lack of knowledge about the ACA, what they will be eligible for, new health insurance vocabulary Inability to afford insurance even with subsidies Lack of enthusiasm for enrolling in Medicaid or purchasing insurance on the Exchange Education needed about how to use new coverage for preventive and primary care, and avoid unnecessary use of emergency rooms and urgent care clinics 19

21 Enhanced Opportunities for Cooperation with the ACA One clinic director commented that with the ACA, it was a new day for collaboration between safety net clinics in Denver. The ACA has exposed the glaring gaps in the system, allowing the safety net clinics to realize that there are not enough providers to serve the population, and that it is in all of their interests to cooperate in closing the gaps. The forthcoming ACA changes present an opportunity for safety net organizations to be less guarded and protective with each other, and to increasingly cooperate in a division of labor between the larger and smaller providers, with the various providers being increasingly recognized for the unique contributions they can make. This enhanced cooperation should lead to better access to and quality of care for lower-income Denver residents. Modeling Enrollment and Access to Care in Denver The Task Force has used the following conceptual model to envision how some of the persons newly eligible for either Medicaid or the new insurance plans on the Exchange will become enrolled and be able to access care (see Figure 4). Figure 4: Eligibility to Care Model A substantial number of uninsured patients currently receive medical care within safety-net clinics. A large safety-net provider, Denver Health, estimates that approximately 17,000 of its patients currently engaged in long-term primary care will be eligible for Medicaid or the Exchange. An additional 20